Dr 2219 Form PDF Details

Have you ever had to fill out a Dr 2219 form? If you're like most people, the answer is probably no. But if you ever have to fill one out, here's what you need to know. The Dr 2219 form is used by doctors to bill Medicare for services provided to patients. It's a complex form, and there are a lot of rules about how it should be filled out. If you're not careful, you can make mistakes that can lead to delays in getting paid or even denied payments from Medicare. In this blog post, we'll walk you through the ins and outs of completing a Dr 2219 form. We'll explain the different sections of the form and provide tips on how to complete them correctly. So whether you're a doctor who needs to submit a claim or a patient who wants to understand what's happening with your bill, read on for all the information you need about the Dr 2219 form!

QuestionAnswer
Form NameDr 2219 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesrenewing handicapped parking placard colorado, persons disabilities parking, persons disabilities parking application, placard medical disabilities

Form Preview Example

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Parking Privileges Application

Persons With Disabilities must meet one of the criteria

below and have it verified in writing by a medical

professional*:

1.Mobility: Persons who cannot walk two-hundred feet without stopping to rest.

2.Assisted Mobility: Persons who cannot walk without the use of, or assistance from, a brace, cane, crutch,

another person, prosthetic device, wheelchair, or other assistive device.

3.Respiratory: Persons who are restricted by lung

disease to such an extent that the person’s forced

(respiratory) expiratory volume for one second when measured by spirometry is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air or at rest.

4.Oxygen: Persons who use portable oxygen.

5.Cardiac: Persons who have a cardiac condition to the

extent that the person’s functional limitations are classified in severity as class III or IV according to the standards of the American Heart Association.

6.Other: Persons who are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

*Professional – licensed professionals from Colorado and bordering states:

•Physician licensed to practice medicine or practicing medicine pursuant to section 12-36-106 (3) (i), C.R.S.,

•Commissioned Medical Officer of the U.S. Armed Forces, the U.S. Public Health Service, and/or the U.S. Veterans Administration.

•Advance Practice Nurse registered pursuant to section 12-38-111.5, C.R.S.

•Physician Assistant licensed pursuant to section

•2-36-107.4, C.R.S.

•Podiatrist licensed under article 32 of title 12, C.R.S.

•Additional professionals for the Short Term Placard only.

•Chiropractor licensed under article 32 of title 12, C.R.S.

•Physical Therapist licensed under article 32 of title 12, C.R.S.

Impairments are defined as follows:

•Permanent: A condition that is not expected to change within a person's lifetime, given the current state of medical or adaptive technology.

•Extended: A condition that is not expected to change within thirty months after the issuance of an identifying figure, given the current state of medical or adaptive technology.

•Temporary: A condition that is expected to last less than thirty months after the issuance of an identifying plate or placard, given the current state of medical or adaptive technology.

•Short Term: A condition that is not expected to last more than 90 days after the issuance of a placard.

•Remuneration-exempt disability means a disability that limits an individual's: (i) fine motor control in both hands; (ii) ability to reach a height of forty-eight inches from the ground due to lack of strength or mobility in the individual's finger, hand, or upper extremity; or (iii) ability to reach or access a parking meter due to the use of a wheelchair or other ambulatory device.

Options Available:

1.Two sets of license plates (fees apply).

2.One set of license plates (fees apply) and one

permanent (blue) no fee placard and one remuneration placard.

3.Up to two permanent (blue) no fee placards and no license plates.

4.One remuneration exempt identifying placard (May not be issued to a parent or guardian of a child under 16 years of age) and one permanent blue placard.

The Department may issue one identifying plate or placard to each parent or guardian of a child with a

disability who is under sixteen years of age to be used only when transporting the child. The Department shall not issue more than two identifying placards, two identifying plates, or one plate and one placard for the child to only to be used when transporting the child. Remuneration cannot be issued to a parent or guardian, minor, or business.

Applicants with Short Term disabilities qualify for the following option:

•One 90-Day no fee Placard (can be renewed with medical professional’s authorization).

(Continued on next page)

1

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Parking Privileges Application

Medical Professional Certification and Self–Certification

Placard Type

Disability Type

Medical Professional

Self-Certification

 

 

Verification

 

Three Year Placards (Blue), three year

Permanent

Initially, then every ninth

Third and sixth year renewal

remuneration-exempt placards (Purple)

 

year (third renewal)

by mail with the form DR 2219

or Plates: Program recertification required

 

 

signed by a professional, or

every three years (by mail or in person) with

 

 

in person with a secure and

completion of DR 2219

 

 

verifiable identification

 

Extended

Initially, then every third

N/A

 

 

year with renewal

 

 

Temporary

Initially, then every third

N/A

 

 

year with renewal

 

Temporary Placard (Red): One only valid

Short-term

Initially, then with 90

N/A

until the last day of the month falling ninety

 

day renewal

 

days after the date of issuance may be

 

 

 

renewed only once with completion of form

 

 

 

DR 2219

 

 

 

 

 

 

 

Physician Certification Instructions

Notice To Providers

Providers who knowingly misuse or who make false statements to help someone obtain or retain disabled parking authorization may be fined up to $500,000 for a Class 4 Felony or $1,000 for a Class one misdemeanor, and subject

to incarceration.

1.Complete the entire form, sign and date.

2.If you make a mistake on this form, please complete a new form. Do not write over, white-out or cross-out information. This will void the form.

3.To sign the form, you must be a Professional as defined below.

a.Professional: licensed professionals from

Colorado and bordering states:

i.Physician licensed to practice medicine or practicing medicine pursuant to

section 12-36-106 (3) (i), C.R.S.,

ii.Commissioned Medical Officer of the U.S. Armed Forces, the U.S. Public Health Service, and/or the U.S. Veterans Administration.

iii.Advance Practice Nurse registered pursuant to section 12-38-111.5, C.R.S.

iv.Physician Assistant licensed pursuant to section 12-36-107.4, C.R.S.

v.Podiatrist licensed under article 32 of title 12, C.R.S.

b.Additional professionals for the Short Term Placard only:

i.Chiropractor licensed under article

32 of title 12, C.R.S.

ii.Physical Therapist licensed under article 32 of title 12, C.R.S.

4.Patients must have a new Professional verification done as part of their renewal process depending on the designated disability (see #5 below). Ensure the

Persons With Disabilities applicant meets one of the criteria below before you verify in writing:

a.Mobility: Persons who cannot walk two-hundred feet without stopping to rest.

b.Assisted Mobility: Persons who cannot walk without the use of, or assistance from, a brace,

cane crutch, another person, prosthetic device, wheelchair, or other assistive device.

c.Respiratory: Persons who are restricted by lung

disease to such an extent that the person’s forced

(respiratory) expiratory volume for one second when measured by spirometry is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air or at rest.

d.Oxygen: Persons who use portable oxygen.

e.Cardiac: Persons who have a cardiac condition to

the extent that the person’s functional limitations are classified in severity as class III or IV according to the standards of the American Heart Association.

(Continued on next page)

2

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Physician Certification Instructions

Notice To Providers

f.Other: Persons who are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

g.Remuneration-exempt qualifying disability:

See 5e for definition.

5.Applicant must meet one of the impairments which are defined as follows:

a.Permanent: A condition that is not expected to change within a person's lifetime, given the current state of medical or adaptive technology.

b.Extended: A condition that is not expected to change within thirty months after the issuance of an identifying figure, given the current state of medical or adaptive technology.

c.Temporary: A condition that is expected to last less than thirty months after the issuance of an identifying plate or placard, given the current state of medical or adaptive technology.

d.Short Term: A condition that is not expected to last more than 90 days after the issuance of a placard.

e.Remuneration-exempt qualifying disability means a disability that limits an individual's:

i.fine motor control in both hands;

ii.ability to reach a height of forty-eight inches from the ground due to lack of strength or mobility in the individual's finger, hand, or upper extremity;

iii.ability to reach or access a parking meter due to the use of a wheelchair or other ambulatory device.

6.Ensure the date reflects the most current patient information. The condition time is based on the date you enter (i.e., extended thirty-months is from the date entered, not the transaction date).

7.Please do not fax or e-mail the form to the Division of Motor Vehicles. The applicant must submit the completed DR 2219 at the time of registration.

8.You may contact the Title and Registration Sections at 303-205-5608 with any questions.

(Continued on next page)

3

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Persons With Disabilities Parking Privileges Application

Name of person with disability or entity representative (please type or print in ink)

 

 

Date of Birth

 

 

 

 

Physical Address

City

State

ZIP

 

 

 

 

Mailing Address (if different from above)

City

State

ZIP

 

 

 

 

I certify, under penalty of perjury, that I have read and understand the Persons with Disabilities plate and placard application and usage requirements and that I am responsible for the use in conformity with Colorado Revised Statutes 42-3-204 and 42-4-1208. I further understand that violation of the requirements in the statutes referenced above may result in fines and penalties up to $5,000, incarceration and community service, and suspension of Persons with Disabilities placards and plates.

Printed name as it appears on identification

Signature

Secure and Verifiable ID of (circle one) Applicant/Legal Guardian/Representative/Entity Representative: (check appropriate box)

Colorado DL

Colorado ID

Identification document issued by

Out of state DL or ID (Only for out of state

 

 

United States Government

residents applying for a short- term placard)

ID Number

 

Expires

DOB

The undersigned witness affirms that the (circle one) applicant/legal guardian/entity representative signing this document presented the identification described above.

Witness Printed Name

Witness Signature

Date

This Section Below Must be Completed by a Professional Defined in Colorado Revised Statute 42-3-204(1)(a) and (i.5)

This Person is Mobility Impaired as Described Below (Check one box) Qualifying criteria are listed below. All criteria require certification by a person fully licensed to practice medicine in Colorado.

Persons who cannot walk two hundred feet without stopping to rest. Persons who use portable oxygen.

Persons who cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device.

Persons who have a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association.

Persons who are restricted by lung disease to such an extent that the person's forced (respiratory) expiratory volume for one second when measured by spirometry is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air or at rest.

Persons who are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition. Remuneration-exempt qualifying disability means a disability that limits an individual's:

i.fine motor control in both hands;

ii.ability to reach a height of forty-eight inches from the ground due to lack of strength or mobility in the individual's finger, hand, or upper extremity;

iii.ability to reach or access a parking meter due to the use of a wheelchair or other ambulatory device.

(Continued on next page)

4

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Persons With Disabilities Parking Privileges Application

(continued)

Medical License Number and Issuing State

Name of Professional (please type or print in ink)

Address

City

State ZIP

I certify, under penalty of perjury, that the above named patient has a physical impairment complying with 23 CFR 1235. I have read and understand Colorado Revised Statute 42-3-204 and 42-4-1208 as they pertain to certifying persons with disabilities and affirm my knowledge of the contents of persons with disabilities notices and documentation made available to me pursuant to 42-3-204(3), C.R.S.

This impairment is:

Permanent* Extended* Temporary* Short Term (will last 90 days or less)

Remuneration- exempt qualifying disability*

*These Placards are valid for and must be renewed every 3 years. (See definitions on the first page). Impairments are defined as follows:

Permanent–A condition that is not expected to change within a person's lifetime, given the current state of medical or adaptive technology.

Extended–A condition that is not expected to change within thirty months after the issuance of an identifying figure, given the current state of medical or adaptive technology.

Temporary–A condition that is expected to last less than thirty months after the issuance of an identifying plate or placard, given the current state of medical or adaptive technology.

Short Term–A condition that is not expected to last more than 90 days after the issuance of a placard (can be renewed

with medical professional’s authorization).

Remuneration-exempt disability means a disability that limits an individual's: (i) fine motor control in both hands;

(ii)ability to reach a height of forty-eight inches from the ground due to lack of strength or mobility in the individual's finger, hand, or upper extremity; or (iii) ability to reach or access a parking meter due to the use of a wheelchair

or other ambulatory device.

**Chiropractors and Physical Therapists may only certify a physical impairment for Short Term Placards.

Providers who knowingly misuse or who make false statements to help someone obtain or retain a placard may be fined up to $500,000 for a Class 4 Felony or $1,000 for a Class one misdemeanor, and subject to incarceration.

(Continued on next page)

5

DR 2219 (12/21/18)

COLORADO DEPARTMENT OF REVENUE

Vehicle Services Unit

www.colorado.gov/dmv

Persons With Disabilities Parking Privileges Application

(continued)

Signature of Professional

Phone Number

Date

Name of person with disability or entity representative (please type or print in ink)

Application For Persons With Disabilities Parking Privileges

There is no fee for persons with disabilities placards. Standard registration fees and ownership taxes will be charged for disability license plates. A plate or placard holder is responsible to safeguard the plate or placard from use by others.

Please choose one option below: Permanent, Extended, and Temporary Disability

•Submit a completed application in the name of the person with a disability.

•Secure and verifiable identification for the person with a disability.

•Power of Attorney appointing an agent.

•Enclose a photocopy of the title or registration to the vehicle.

Persons with Disabilities with Vehicle (Check one option below)

1 Plates

2 Plates

1 Plate and 1 Placard

1 Placard

2 Placards

1 Plate and 1 Remuneration Placard

1 Placard and 1 Remuneration Placard

Persons with Disabilities without a Vehicle (Check one option below)

1 Placard

2 Placards

1 Placard and 1 Remuneration Placard

Short Term (90-Day) Disability

Temporary (90-Day) no fee Placard–For persons with a short term disability to the degree described on page one of this form.

•Submit a completed application in the name of the person with a disability.

•A 90-day temporary placard will be issued which is to be placed inside the vehicle of which the person with a disability is a passenger.

•The placard is movable from one vehicle to another.

•Out of state applicants can submit their out of state drivers license, identfication document or United States Government identification document

Signature

Date

6

How to Edit Dr 2219 Form Online for Free

dr2219 can be filled in in no time. Simply make use of FormsPal PDF editing tool to complete the task fast. To make our tool better and more convenient to utilize, we constantly develop new features, with our users' suggestions in mind. Getting underway is easy! All that you should do is follow these simple steps below:

Step 1: First, access the pdf editor by pressing the "Get Form Button" at the top of this site.

Step 2: When you open the online editor, you will get the document ready to be filled out. Apart from filling in various fields, you may also perform several other things with the form, specifically putting on custom text, modifying the initial text, adding images, putting your signature on the form, and more.

Filling out this document requires attention to detail. Make certain all necessary areas are filled out correctly.

1. For starters, once completing the dr2219, beging with the page containing next blank fields:

persons disabilities parking writing process detailed (part 1)

2. Right after finishing the last step, go to the subsequent stage and enter all required particulars in these blanks - This Section Below Must be, require certification by a person, fine motor control in both hands, i ii ability to reach a height of, individuals finger hand or upper, and iii ability to reach or access a.

Part no. 2 of filling out persons disabilities parking

Concerning i ii ability to reach a height of and fine motor control in both hands, ensure that you review things here. The two of these are the most significant ones in the form.

3. This step will be easy - fill out every one of the fields in Medical License Number and Issuing, Name of Professional please type, Address, City, State ZIP, I certify under penalty of perjury, This impairment is, Permanent Remuneration exempt, Extended, Temporary, Short Term will last days or less, These Placards are valid for and, adaptive technology, ExtendedA condition that is not, and the current state of medical or to complete this segment.

State ZIP, Extended, and Address in persons disabilities parking

4. The following part needs your attention in the subsequent places: Signature of Professional, Phone Number, Date, Name of person with disability or, Application For Persons With, There is no fee for persons with, Submit a completed application in, Persons with Disabilities with, Plates, Plates, Plate and Placard, Placard, Placards, Plate and Remuneration Placard, and Placard and Remuneration Placard. Be sure you fill in all required information to move forward.

Stage # 4 in filling in persons disabilities parking

5. As a final point, this last subsection is precisely what you will need to complete before submitting the document. The blank fields you're looking at include the next: Government identification document, Signature, and Date.

Government identification document, Signature, and Date of persons disabilities parking

Step 3: Prior to finalizing this document, it's a good idea to ensure that blank fields are filled out the correct way. As soon as you believe it is all good, click “Done." Join FormsPal right now and instantly get dr2219, all set for download. All adjustments made by you are saved , helping you to customize the file later on as required. We do not share or sell any information you enter while filling out documents at FormsPal.

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